Provider Demographics
NPI:1932192416
Name:TASCHE, BEVERLY LORRAINE (PAC)
Entity Type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:LORRAINE
Last Name:TASCHE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:BEVERLY
Other - Middle Name:LORRAINE
Other - Last Name:BIRCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1525 MADISON ST
Mailing Address - Street 2:STE 2
Mailing Address - City:FREDONIA
Mailing Address - State:KS
Mailing Address - Zip Code:66736-1704
Mailing Address - Country:US
Mailing Address - Phone:620-378-2068
Mailing Address - Fax:620-378-2312
Practice Address - Street 1:1525 MADISON ST
Practice Address - Street 2:STE 2
Practice Address - City:FREDONIA
Practice Address - State:KS
Practice Address - Zip Code:66736-1704
Practice Address - Country:US
Practice Address - Phone:620-378-2068
Practice Address - Fax:620-378-2312
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500290363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0000427259OtherBLUE CROSS BLUE SHIELD OF KANSAS
KS100003170CMedicaid
KSR78055Medicare UPIN
KS100003170CMedicaid